Infant Feeding Disparities Amid the Formula Shortage: Where Do We Go From Here?

In this issue of Pediatrics, Estruel and Andreyeva use a rigorous quasi-experimental study design and national birth certificate data to estimate the causal effect of the 2022 infant formula shortage on trends in breastfeeding initiation.¹ Overall, they demonstrate that the national breastfeeding initiation rate increased nearly 2 percentage points after the major Abbott Nutrition plant closure and formula recall. The rate then declined again but remained modestly elevated above preshortage levels as the crisis was resolving. Notably, shortage-associated increases in breastfeeding initiation were most pronounced among subgroups with historically higher rates of formula feeding, including Medicaid recipients; non-Hispanic Black mothers; Special Supplemental Program for Women, Infants, and Children (WIC) participants; and those with lower education levels or who live in less populous settings. Consequently, preexisting disparities in breastfeeding initiation affecting these groups narrowed.

At face value, it is promising that breastfeeding initiation disparities have lessened. However, it is important to consider that improvements occurred under duress rather than by intentional design. As the authors note, many structural and policy factors contribute to breastfeeding disparities. In particular, structural racism shapes patterns of opportunity and life experiences that affect breastfeeding feasibility, initiation, and continuation. For example, Black mothers’ infant feeding practices are influenced by experiences of racism, the need to return early to work, and inadequate lactation support in health care facilities and the workplace.² In addition, infant formula marketing that inaccurately portrays formula feeding as more nutritiously advantageous has historically targeted Black families.³ The formula shortage did not solve any of these issues and may even highlight additional sociocultural phenomena at play. As the authors posit, for example, the higher shortage-related increase in breastfeeding initiation among non-Hispanic Black mothers may be secondary to institutional distrust exacerbating concerns about formula contamination and infant safety.

Nevertheless, the study is a welcome addition to the currently sparse literature on the shortage’s impact on breastfeeding disparities. Given limited data availability, the gains described are restricted to breastfeeding initiation for infants born within 10 months of the shortage’s onset. The authors were unable to assess breastfeeding exclusivity or continuity or longer-term consequences on breastfeeding initiation. Importantly, they note that the reopening of the Abbott plant and suspension of formula import tariffs in June 2022 correlate with a backslide in shortage-related gains in breastfeeding initiation. This finding may reflect that preexisting barriers impeding breastfeeding initiation remain pervasive and were only temporarily masked during the shortage due to lack of alternative options. More optimistically, however, breastfeeding initiation rates did remain modestly higher than preshortage levels despite the backslide, which warrants further exploration into potential protective mechanisms. Additional studies analyzing breastfeeding rates with similarly rigorous methodology are needed to understand ongoing trends. Evaluating breastfeeding initiation, exclusivity, and continuity in the months to years to come, as well as facilitators and barriers among disparity-affected subgroups, are vital to improving breastfeeding equity.

The formula shortage–related national shift in infant feeding practices identified by Estruel and Andreyeva represents an opportunity to potentiate the crisis’ positive effects by advocating for policy interventions to support lactation, especially for historically marginalized populations. For example, the authors discuss how inadequate access to lactation spaces may disproportionately affect service industry workers, citing the PUMP for Nursing Mothers Act of 2022 as an important step toward expanding access to lactation spaces and codifying the right to legal action if appropriate space is denied.⁴ Yet the law requires a high degree of self-advocacy, which may be challenging for those with less education or greater workplace power imbalances. Ongoing advocacy by family health–focused medical-legal partnerships may be needed in this arena. Additionally, expansion of paid family leave has been demonstrated to improve breastfeeding continuation, particularly when individuals are granted 12 or more weeks.⁵ The Family and Medical Insurance Leave Act, introduced in Congress in 2023, is one promising legislative avenue to amplify family leave protections particularly for service workers.⁶ Lastly, strengthening lactation supports within both WIC and Medicaid holds potential for breastfeeding promotion and disparity reduction, particularly among the racially and ethnically minoritized groups disproportionately enrolled in these programs.⁷ Specific programmatic improvements could include an increase in Medicaid coverage for prenatal breastfeeding education and breast pump supplies, coordination between both agencies to ensure coverage for and timely access to outpatient lactation services (including expanded telemedicine options), and automation of WIC registration at birth or with Medicaid enrollment to avoid service delays. These equity-promoting policies hold promise for helping solidify breastfeeding as a sustainable method of infant feeding.

While the US formula shortage garnered global media attention for the distress it caused to families, the current study highlights its positive sequelae on breastfeeding initiation. Pediatric practitioners and policymakers should build on this opportunity by advocating for and implementing policies that foster structural improvements in lactation supports beyond the peripartum period, with special attention to understanding and addressing the historical context of preexisting breastfeeding disparities.

WIC

Special Supplemental Program for Women, Infants, and Children